(A) Each request for information regarding a current or previous client shall be accompanied by an authorization for release of information, except as specified in section 5122.31 of the Revised Code.
(B) The authorization for release of information shall include, but not be limited to, the following:
(1) The full name of the client;
(2) Date of birth of the client;
(3) The specific information to be disclosed;
(4) The name of the person or entity disclosing the information;
(5) The name of the person or entity receiving the information;
(6) The date, event, or condition upon which the authorization shall expire, not to exceed six months from the date of its completion, unless documentation reflects that the client agrees to a longer authorization period;
(7) A statement notifying the client of his/her right to shorten or lengthen the authorization period, as well as his/her right to revoke the authorization at any time; and
(8) The dated signature of the client or, as appropriate, a legally authorized agent and the agent's relationship to the client.
119.032 review dates:
Promulgated Under: 119.03
Statutory Authority: 5119.61(A) , 5119.611(C) , 5122.31
Rule Amplifies: 5119.61(A) , 5119.611(C) , 5122.31
Prior Effective Dates: 9/4/03